Faculty Bibliography

There is some, but inconsistent, evidence to suggest that matching patient treatment preference enhances treatment engagement and outcome. The current study examined differential preferences and factors associated with treatment preference for 12-week group cognitive behavioral therapy (CBT), yoga, or stress education in 226 adults with generalized anxiety disorder (GAD; 70% female, Mean age = 33 ± 13.5). In a subsample of 165 patients who reported an intervention preference and were randomized to yoga or CBT, we further examined whether match to preferred intervention improved the primary treatment outcome (responder status on Clinical Global Impressions Scale) and engagement (dropout, homework compliance). Preferences for CBT (44%) and yoga (40%) were similar among patients. Women tended to prefer yoga (OR = 2.75, p = .01) and CBT preference was associated with higher baseline perceived stress (OR = 0.92, p = .04) and self-consciousness meta-cognitions (OR = 0.90, p = .02). Among those not matched to their preference, treatment response was higher for those receiving CBT than yoga (OR = 11.73, p = .013); there were no group differences for those matched to their treatment preference. In yoga, those who received their preference were more likely to drop than those who did not (OR = 3.02, 95% CI = [1.20, 7.58], p = .037). This was not the case for CBT (OR = 0.37, 95% CI = [0.13, 1.03], p = .076). Preference match did not predict homework compliance. Overall, results suggest that treatment preference may be important to consider to optimize outcome and engagement; however, it may vary by treatment modality. Future research incorporating preference, especially with yoga for anxiety, is aligned with personalized medicine. TRIAL REGISTRATION: clinicaltrials.gov: NCT01912287; https://clinicaltrials.gov/ct2/show/NCT01912287.

For interventions that affect how individuals interact, social network data may aid in understanding the mechanisms through which an intervention is effective. Social networks may even be an intermediate outcome observed prior to end of the study. In fact, social networks may also mediate the effects of the intervention on the outcome of interest, and Sweet (2019) introduced a statistical model for social networks as mediators in network-level interventions. We build on their approach and introduce a new model in which the network is a mediator using a latent space approach. We investigate our model through a simulation study and a real-world analysis of teacher advice-seeking networks.

OBJECTIVE:We examined whether relative availability of fast-food restaurants and supermarkets mediates the association between worse neighborhood socioeconomic conditions and risk of developing type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS/METHODS:As part of the Diabetes Location, Environmental Attributes, and Disparities Network, three academic institutions used harmonized environmental data sources and analytic methods in three distinct study samples: (1) the Veterans Administration Diabetes Risk (VADR) cohort, a national administrative cohort of 4.1 million diabetes-free veterans developed using electronic health records (EHRs); (2) Reasons for Geographic and Racial Differences in Stroke (REGARDS), a longitudinal, epidemiologic cohort with Stroke Belt region oversampling (N = 11,208); and (3) Geisinger/Johns Hopkins University (G/JHU), an EHR-based, nested case-control study of 15,888 patients with new-onset T2D and of matched control participants in Pennsylvania. A census tract-level measure of neighborhood socioeconomic environment (NSEE) was developed as a community type-specific z-score sum. Baseline food-environment mediators included percentages of (1) fast-food restaurants and (2) food retail establishments that are supermarkets. Natural direct and indirect mediating effects were modeled; results were stratified across four community types: higher-density urban, lower-density urban, suburban/small town, and rural. RESULTS:Across studies, worse NSEE was associated with higher T2D risk. In VADR, relative availability of fast-food restaurants and supermarkets was positively and negatively associated with T2D, respectively, whereas associations in REGARDS and G/JHU geographies were mixed. Mediation results suggested that little to none of the NSEE-diabetes associations were mediated through food-environment pathways. CONCLUSIONS:Worse neighborhood socioeconomic conditions were associated with higher T2D risk, yet associations are likely not mediated through food-environment pathways.

BACKGROUND:Large-scale longitudinal studies evaluating influences of the built environment on risk for type 2 diabetes (T2D) are scarce, and findings have been inconsistent. OBJECTIVE:To evaluate whether land use environment (LUE), a proxy of neighborhood walkability, is associated with T2D risk across different US community types, and to assess whether the association is modified by food environment. METHODS:The Veteran's Administration Diabetes Risk (VADR) study is a retrospective cohort of diabetes-free US veteran patients enrolled in VA primary care facilities nationwide from January 1, 2008, to December 31, 2016, and followed longitudinally through December 31, 2018. A total of 4,096,629 patients had baseline addresses available in electronic health records that were geocoded and assigned a census tract-level LUE score. LUE scores were divided into quartiles, where a higher score indicated higher neighborhood walkability levels. New diagnoses for T2D were identified using a published computable phenotype. Adjusted time-to-event analyses using piecewise exponential models were fit within four strata of community types (higher-density urban, lower-density urban, suburban/small town, and rural). We also evaluated effect modification by tract-level food environment measures within each stratum. RESULTS:In adjusted analyses, higher LUE had a protective effect on T2D risk in rural and suburban/small town communities (linear quartile trend test p-value <0.001). However, in lower density urban communities, higher LUE increased T2D risk (linear quartile trend test p-value <0.001) and no association was found in higher density urban communities (linear quartile trend test p-value = 0.317). Particularly strong protective effects were observed for veterans living in suburban/small towns with more supermarkets and more walkable spaces (p-interaction = 0.001). CONCLUSION/CONCLUSIONS:Among veterans, LUE may influence T2D risk, particularly in rural and suburban communities. Food environment may modify the association between LUE and T2D.

BACKGROUND:Participation in ambulatory cardiac rehabilitation remains low, especially among older adults. Although mobile health cardiac rehabilitation (mHealth-CR) provides a novel opportunity to deliver care, age-specific impairments may limit older adults' uptake, and efficacy data are currently lacking. OBJECTIVE:This study aims to describe the design of the rehabilitation using mobile health for older adults with ischemic heart disease in the home setting (RESILIENT) trial. METHODS:RESILIENT is a multicenter randomized clinical trial that is enrolling patients aged ≥65 years with ischemic heart disease in a 3:1 ratio to either an intervention (mHealth-CR) or control (usual care) arm, with a target sample size of 400 participants. mHealth-CR consists of a commercially available mobile health software platform coupled with weekly exercise therapist sessions to review progress and set new activity goals. The primary outcome is a change in functional mobility (6-minute walk distance), which is measured at baseline and 3 months. Secondary outcomes are health status, goal attainment, hospital readmission, and mortality. Among intervention participants, engagement with the mHealth-CR platform will be analyzed to understand the characteristics that determine different patterns of use (eg, persistent high engagement and declining engagement). RESULTS:As of December 2021, the RESILIENT trial had enrolled 116 participants. Enrollment is projected to continue until October 2023. The trial results are expected to be reported in 2024. CONCLUSIONS:The RESILIENT trial will generate important evidence about the efficacy of mHealth-CR among older adults in multiple domains and characteristics that determine the sustained use of mHealth-CR. These findings will help design future precision medicine approaches to mobile health implementation in older adults. This knowledge is especially important in light of the COVID-19 pandemic that has shifted much of health care to a remote, internet-based setting. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT03978130; https://clinicaltrials.gov/ct2/show/NCT03978130. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)/UNASSIGNED:DERR1-10.2196/32163.

Families of color living in historically disinvested neighborhoods face a multitude of health disparities which have been exacerbated by COVID-19 and the resulting strategies to mitigate its transmission. School closure, which occurred with little warning and few, if any, resources for preparation, disrupted multiple aspects of families' lives; these disruptions are anticipated to adversely impact mental health and well-being. The current study aims to advance understanding of the experiences of families of young children of color during the pandemic by utilizing a natural experiment design to test impact on child and parent mental health and sleep in the context of COVID-19 related school closure among families in historically disinvested neighborhoods. Data from this study come from an ongoing study of 281 families of color enrolled in 41 pre-kindergarten (pre-K) programs in neighborhoods across New York City (NYC). In NYC, school closure occurred on March 16, 2020, during a data collection period involving phone surveys with parents; the quasi-experimental design allows for comparison of the 198 families who had completed the survey prior to March 16, and the 83 families who completed the survey after March 16, using identical protocols and procedures. Results demonstrate poorer mental health among parents surveyed after school closure as compared to before school closure. No differences were found for parent sleep, child mental health, or child sleep. Implications of this work highlight the need for structural and systemic supports for families faced with compounding stressors as a result of the COVID-19 pandemic and related school closure.

Background: Mobile health cardiac rehabilitation (mHealth-CR) may improve outcomes among older adults with ischemic heart disease, but variable engagement is not yet understood. We therefore analyzed preliminary data from the RESILIENT trial, an ongoing randomized trial of mHealth-CR vs. usual care in patients age >= 65.
Method(s): Data from the first 50 intervention participants were analyzed. Weekly engagement was scored from 0-11 based on exercise completion, therapist communication, video viewing, and BP self-measurement. Participants were classified as high or low engagement based on median engagement scores. Groups were compared by age, sex, social support (living alone), depression (PHQ-8), and Charlson Comorbidity Index (CCI).
Result(s): There was widely varying engagement with mHealth-CR that ranged from nearly zero to nearly perfect engagement (Figure). There were no significant differences between high and low engagement groups based on mean age (72.6 vs. 72.8, P=0.8), sex (76% male vs. 80%, P=0.7), living alone (28% vs. 44%, P=0.2), depression (mean 3.9 vs. 4.6, P=0.5), or comorbidity burden (mean 4.4 vs. 4.8, P=0.3), although the sample size was small.
Conclusion(s): Our early findings show wide variation in mHealth-CR engagement among older adults